After the save: A drug can reverse an overdose. Then what?
Norwich – Dr. William Horgan has seen his share of patients go through life-changing experiences – and the changes that come from them.
“A chronic smoker who has a heart attack and then recovers, the likelihood of them picking a cigarette back up is so infinitesimally small,” said Horgan, the associate chief of emergency services at Backus Hospital in Norwich.
But heroin is different, Horgan says: Its grip is so strong, it seems to defy that logic.
When patients come into his emergency room after overdosing and being revived by the opioid antidote naloxone, it’s not uncommon for them to leave soon after, in withdrawal, to use again.
“They’re so quick to go back to it, it’s frightening,” Horgan said. “You feel useless.”
The wider availability of naloxone, the drug that can reverse opioid overdoses, is the result of efforts by Connecticut policymakers to respond to the opioid epidemic. Experts say it’s a vital tool, but in many ways, a short-term one: Naloxone saves lives, but it doesn’t necessarily change them.
What else can help? The Backus Hospital emergency room is part of a pilot program that tries to capitalize on the potential for an overdose to be a turning point, by connecting people who overdose with professionals who can nudge them toward recovery.
Now, when a patient comes in after overdosing, a nurse calls the mobile outreach team run by the state’s Southeastern Mental Health Authority. They dispatch a clinician who talks to the patient and offers guidance on resources. They follow up afterward.
“You’re going to catch people at a pretty critical moment,” said Jeff Watson, one of the clinicians. “Sometimes you can get in and tip the scale a little bit.”
The Backus program is akin to giving a patient with a broken leg a follow-up appointment with an orthopedist before leaving the emergency department, said Mary Kate Mason, spokeswoman for the state Department of Mental Health and Addiction Services. But as a practice for patients who overdose, “it was a huge shift,” she said.
Since July 2015, the team has been called for 120 overdose cases at Backus. Seventy-six percent of the patients agreed to a follow-up.
“If that many people are willing to say yes, that’s a big deal,” Mason said. “That’s a moment that we have that we should capture as often as we can.”
The department is working on an initiative to build on the concept, using “recovery coaches” – people in recovery from addiction who can serve as peer mentors to the patients and help connect them to resources – in other hospitals.
Many legislators list the opioid crisis as among their top priorities to address. Some also have wondered how to translate the overdose reversals that come from naloxone into longer-term recovery.
“Are we enrolling them in the appropriate kind of supportive health [care] that they need, or are we just giving them the Narcan and that’s it, that’s done, the end of the day?” asked Rep. Prasad Srinivasan, R-Glastonbury, using the brand name for a form of naloxone. “They need to be connected to some kind of a social network, both professional and nonprofessional, so that they do not just become constant offenders.”
But experts say there are challenges to trying to counsel patients who have just been administered the overdose-reversal drug. Naloxone launches a person into painful withdrawal. Some people become uncomfortable and confused. Some are angry that their high was disrupted.
“You have to remember, if somebody’s overdosed, the last thing they remember was being very high, which for some people, was exactly the goal,” said Janine Sullivan-Wiley, executive director of the Northwest Regional Mental Health Board in Waterbury. “And the next thing they know, they’re waking up sick as a dog because they’re put into abrupt and complete withdrawal. This is not a gentle landing.”
Watson, the supervising clinician for the mobile outreach team, knows that. His team works to prevent and respond to crises. They fit the emergency-room visits into their other responsibilities.
When he’s called to Backus, he brings a packet of information on recovery resources and, after introducing himself, often leads with an open-ended question: What happened?
“The first mission is to try to get an interpersonal connection with folks,” he said. “And that works, or doesn’t work.”
Sometimes the conversation lasts an hour and they talk about how the person ended up overdosing and ways to get help. Other times, the person is less receptive. One man Watson’s team met recently was ambivalent, unsure he needed help.
“My colleagues spent some time saying, ‘Well, and yet you’re here, and yet they used Narcan,’” Watson said.
The man wasn’t convinced. But he took the packet of information. That means that at some point, if he “gets it” and decides he wants help, he’ll have a place to start, Watson said.
Some flat out ask Watson or his colleagues to leave, but that’s happened less often than he thought it would.
“Usually people are kind of stunned that this has all happened, and it’s a good opportunity for them to talk,” he said. “When you let them kind of talk about what happened, it begins the process where they start looking at what’s going on.”
Watson sees his role as helping people move through what some behavioral experts call the “stages of change.” Those stages range from “pre-contemplators” (“I do a little heroin, so what?”) who are likely to tell him to get lost, to “contemplators” who think their drug use is starting to become a problem and might be more receptive, to those who want to take action and will grab any resources he can provide.
It’s not a linear process. Some will be motivated to change in the emergency room but lose the resolve the next day.
“It goes back and forth, but every time we can nudge it forward, that’s a step,” Watson said. “But you never know how far it’s going to go because we don’t get the long view all the time.”
‘How soon can you do this?’
The Department of Mental Health and Addiction Services plans to fund a similar program at four hospitals. It will have recovery coaches from the organization Connecticut Community for Addiction Recovery on call to meet with people in emergency rooms.
Two of the four hospitals are Windham and Backus, both part of Hartford HealthCare. Patricia Rehmer, president of the Hartford HealthCare Behavioral Health Network, recently met with the ER directors and nursing directors at the hospitals about what they could expect. She thought there would be some resistance.
Instead, they asked, “How soon can you do this?”
“Because the emergency rooms are just so overwhelmed with individuals that are coming in that have been brought back by Narcan, or people that come in over and over again who are often abusing alcohol,” Rehmer said.
Chris Burke, behavioral health clinical manager for the mobile outreach team, was similarly surprised by how receptive people have been.
“Everywhere we went, the nurses at the ED had personal experiences. The cops out in the field were having personal experiences with family friends,” he said. “Everyone knew someone that was going through a really terrible time with this and totally powerless as to what to do.”
Horgan said the Backus emergency department still sees patients who overdosed on a daily basis. The real key, he believes, is prevention, finding a way to keep people from starting the drugs.
But for those who have and come to the ER, having outreach workers available to talk with and find resources can make a difference, particularly for those who have few people to turn to because of their addictions.
“It’s doing something, whereas before we were doing nothing, and so we’re getting there,” Horgan said. “It’s baby steps.”
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